More Francis inquiry response

Clare Horton writes

Writing on the Institute for Government blog, Nicholas Timmins says the Francis report should be the start of a debate. The report, he adds, risks producing more bureaucracy and a new army of inspectors. He concludes:

Amid the fevered reaction to Francis, and the overwhelming sense that “something must be done”, ministers need to think long and hard about what that something should be. Francis should be the start of a debate, not the automatically endorsed solution.

What’s needed is a change in culture in the NHS to ensure that everyone is treated with dignity and respect. This cannot be achieved by political fiat. Every hospital must create a climate in which staff are encouraged to treat patients as well as they can.

Robert Francis has recognised this in his report and the task now is to implement his recommendations to ensure that another inquiry like this will not be needed again. The priority must be to shift from a culture in which the behaviour of staff is driven by compliance with targets to one in which there is a real commitment to patient-centred care in every hospital and surgery.

If its recommendations are implemented and are seen to have the desired effect then (and only then) can we or anyone else claim to have learned from this.

It adds:

This distinction matters because in the bad old days, project managers would hastily write an end of project report, add in a ‘lessons learned’ annex and that would be that.

No changes would happen. No learning would take place.

At best, some months or years later, a newly-appointed project manager might retrieve the report in order to see what his predecessor had done. However, since the ‘lessons’ had lain dormant for the intervening period, no organisational changes had taken place (i.e. no restructuring, no policy refinements, no process re-engineering, no strategy review) and therefore the new project would begin with the organisation in exactly the same state as at the end of the previous project.

Don Berwick has been appointed to spearhead a “zero harm” agenda in the NHS following yesterday's report into the scandal at Mid Staffordshire hospitals.

In a video interview with the Nuffield Trust last year Dr Berwick, former President and CEO of the Institute for Healthcare Improvement, speaks to Simon Stevens, President of Global Health at UnitedHealth Group, about the progress of health reform in the US and the UK, and how health care systems might adapt and prosper in these straitened financial times.

The personalisation agenda is surely one of the biggest challenges facing healthcare. Firstly, because to personalise healthcare there needs to be wider recognition that choice is far more fundamental than simply where people can go for their treatment. It is about recognising the lack of certainty that is associated with many healthcare interventions and that, as a consequence, choosing the right course of treatment (including the choice to do nothing) will depend on the trade-offs individuals are prepared to make.

And secondly it’s a challenge – we need to realise that the NHS’s role in ‘looking after’ people who are unwell is pretty limited. People are looking after their own health every moment of their life – for better or worse. If the NHS can equip us to do that better, rather than taking on the responsibility itself, there could be significant health gains to be achieved.

NHS chief Sir David Nicholson has said in an interview with ITV that he visited wards at Stafford hospital during the period when the abuse outlined in the Francis report was taking place, but that he didn't notice anything of concern.

The Francis report calls for more openness, transparency and candour in order to create and underpin a "common culture of caring" throughout the NHS. It is telling that he does not say that more transparency, ie publishing data, alone will deliver this culture change. Transparency must go alongside more openness, enabling questions to be raised and answered, and honesty, being proactive in admitting failings, in all the NHS's dealings with patients and the public. CfPS's research strongly supports this argument.

Stewart Jackson MP, a senior member of the committee of public accounts today said:

The strategic management of health resources across the East of England Strategic Health Authority has failed. Ultimate responsibility for this rests with the Department of Health.

Circle Healthcare, the franchisee of Hinchingbrooke, has not achieved its expected savings in its first few months and its chief executive has already left. We are concerned that the bid was not properly risk-assessed and the successful bidder was encouraged to submit over-optimistic savings projections.

The PFI deal for Peterborough and Stamford PFI hospital has proved catastrophic, with the Department now being forced to pay out nearly £1 million a week of taxpayers’ money to keep the Trust afloat.

Dr Mark Newbold, chief executive of Heart of England NHS foundation trust and chair of the NHS Confederation's hospitals forum gives his response to the Francis Report in this video, which is also worth a quick view.

Richard Vize argues the Francis report recommendations can be implemented by the imminent restructuring of the health services, but it will take a while to change bad habits, in a piece that we've just launched on the network.

"Someone has to make the first move," he says.

Vize adds:

Implementing Francis in each trust will require management skills of the highest order. For example, a duty of candour and a requirement to put patients first could easily mutate into dumping problems on other staff. Is a ward sister who demands to have more nurses before she accepts more patients living the Francis dream or becoming a management nightmare? Will managers now be so fearful of jeopardising safety that they will allow their trust to run into deficit?

One thing that cannot change is the focus on money, because poor financial control inevitably leads to poor care and crisis. Not compromising safety or quality in the interests of money is easy to write but rather more difficult to achieve.

The most obvious pressure point is staffing levels, whether it be an unacceptably high ratios of patients to nurses or unsafe consultant cover at weekends. Should services close rather than scrape by? With the new exhortation to prosecute staff for "non-compliance with a fundamental standard" that leads to death or serious harm, many managers and clinicians should now be wondering if that is the route they need to take.

The Francis recommendations are powerful tools for improvement in the NHS but they are not a panacea. They create their own pressures, contradictions and difficulties, and the cultural change to deliver them is going to take many years.

Francis report: responses from the sector

The evidence shows that incidents like those reported at Mid Staffordshire Foundation Trust where failures were so serious, so protracted and had such a devastating and widespread patient impact are rare and isolated. It is clear, however, that pockets of poor care do exist right the way across the NHS. Hopefully the Francis report will now help us get to the nub of why poor care continues despite persistent attempts by trusts to resolve this complex problem. Trust boards, commissioners, regulators and staff need to work together to create a culture where patients and their voices are truly at the heart of the NHS.

He specifically says that ‘a leadership college should be created to provide common professional training in management and leadership’ and that it ‘should be a physical presence that will serve the role of reinforcing the required culture through shared experience and will provide a common induction into the expectations of the NHS of those who lead and work in the system.’

The NHS Leadership Academy is, I believe, the organisation Robert Francis envisions for the NHS.

Jan Sobieraj is managing director of the NHS Leadership Academy.

Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing, said:

The RCN welcomes this powerful and monumental report which puts patients at the heart of NHS care. It delivers key recommendations which we support and have been calling for, including the registration and regulation of health care assistants. We welcome moves for overarching standards which enshrine what patients deserve from the NHS and from those who work for it.

He added: “Appalling care cannot be tolerated and everything should be done to ensure that it does not happen again."

I have been profoundly disturbed and saddened to hear again how a series of failures at Mid Staffordshire NHS Trust resulted in such tragedy for so many patients and their families. The accounts of appalling and unnecessary suffering are truly shocking.

It is not enough to say that lessons must be learnt. It is essential that we all - politicians, NHS organisations, doctors, managers, nurses, and patient groups - work together to develop a different kind of health service where the system will not tolerate poor quality of care.

... We must urgently develop a new culture - everyone working in the health service must play their part, and be allowed to play their part, in practising zero tolerance to poor and dangerous care.

As with every other area in life, providing healthcare is not risk-free and it never will be; the art and science of medicine is in balancing those risks. But we must create an urgent shift towards a more open and transparent approach that values learning from mistakes and puts the patient experience at the centre of our thoughts and reflections. We need good systems and data to enable clinical teams to spot problems early on – and make things better.

The Academy of Medical Royal Colleges said in a statement:

Quality of care must be the foremost priority for all involved in the delivery of health services. That was not the culture in Mid Staffordshire. All professionals from the medical and nursing profession to managers have a share in the responsibility for this failing. As such we express our profound regret for the breakdowns in professional standards experienced by patients and their families.

We believe that poor care is not everywhere in the NHS but has the potential to happen anywhere. Many doctors will have had experience of aspects of what happened at Mid Staffordshire. Within organisations which in overall terms provide a good standard of care there can be departments, wards or teams where standards fall below what is acceptable.

The delivery of quality care is a shared responsibility and all parts of the healthcare system – politicians, national leaders, managers and clinicians – must really listen to and hear what is said to them by patients and carers to ensure that quality of care, patient safety and patient experience are truly the central drivers of what happens in the NHS.

What Francis is saying chimes with what the FTGA believes is the governor’s role - to encourage openness and accountability between trusts, patients and the public.

For our members, the report’s central recommendation - that trusts should ensure openness, transparency and candour throughout the system about matters of concern - is vital.

Our members can’t do their jobs if trusts don’t consistently share information about the way they measure and understand the performance of professionals, teams and managers.

She added: “The FTGA recognises that governors come from a variety of backgrounds and that as a result they can be difficult to manage. However, it is exactly this diversity that provides strength to the body and confidence to the public that their oversight cannot be impeached.”

The leadership group of NHS Clinical Commissioners said the report made uncomfortable reading for anyone working in the health sector. The group added:

It is clear that there is a collective responsibility to ensure that failures such as happened at Mid Staffordshire NHS Trust do not happen again.

As the leaders within Clinical Commissioning Groups we recognise that quality is the personal responsibility of all who work in the NHS and we cannot delegate that responsibility to anybody else.

... We will respond positively to the challenges in the Report and we will use our position to play a central role in shaping and using the new more local commissioning system to be one that places patients at the centre of our decision-making and keeps them there in monitoring the quality and outcomes of care we commission.

Responsibility for promoting and assuring high quality care must be owned not just by the governing bodies and executives of Clinical Commissioning Groups, but also by all member practices.

Engagement of those at the front line of general practice is central so CCGs can genuinely be a collective voice for all primary care professionals; CCGs must engage with their members to ensure knowledge of patients experience held in local primary care is shared to improve quality for all.

Operated by the Chelsea and Westminster hospital's sexual health centre in Soho, 56 Dean Street, in conjunction with the remote healthcare specialist DrThom and the gay dating site Gaydar, the Dean Street at Home initiative uses the principles of online marketing to diagnose HIV efficiently through careful targeting.

Gaydar brings together people with a relatively high risk of having or contracting HIV, so users are sent messages offering a free risk assessment. DrThom then offers a free HIV home-sampling kit to participants via the post so they could give a sample from the privacy of their own homes.

These are then sent off to the laboratory and the test results sent back to DrThom. Those who test negative are informed by SMS; those whose sample proves "reactive" are contacted by the NHS doctors of 56 Dean Street and offered further advice and testing.

When things go wrong, as they often do, it’s because there’s a culture of things going wrong, and it’s a culture that’s been set at the top. When things go wrong, it’s because there are bad managers, and bad communication, and bad relations between different levels in the organisation, and between different types of staff. When things go wrong, it’s because managers haven’t been talking to their staff, or watching what they do, or making sure they’re doing everything they can to help them do their jobs better. When things go wrong, it’s because they’re not listening to patients’ bad experiences, and they’re not doing everything they can to make sure they never happen again.

Good hospitals have clear management structures, clear communication with staff and with patients, and make it very clear to everyone who’s responsible for what. Good hospitals publish and display their patient feedback and don’t make excuses when things go wrong. Good hospitals inspire their managers to inspire their staff to do their jobs better. They reward them when they do well, and hold them to account when they don’t.

Roy Lilley's NHS Managers blog has a guest post from Prof Brian Edwards, who says challenging change is on the way, and adds: "The good news is that he has not recommended yet another round of organisational change."

... sometimes the House of Commons can speak for the country – and that is what the Prime Minister did yesterday. His tone was echoed by the leader of the opposition, Ed Miliband. David Cameron could have tried developing a very different tone but instead made it clear that Francis had said that Mid Staffs was not caused by any single policy or any single Secretary of State.

He specifically rejected any attempt to scapegoat.

... In terms of Mid Staffs he will have disappointed perhaps even some readers of this blog, those who believe that the only really tough response to events such as these is to find scapegoats.

They would be wrong.

The correct response to events such as these is to put things right, and this is what the PM and the leader of the opposition began to do yesterday.

It will take three weeks for the Government to respond to Francis and it will take the rest of us at least that long to work through its 290 recommendations.

There is a lingering suspicion that the government will seek to use the Francis report as cover to further its own agenda – and there were unfortunately signs of this in Mr Cameron's attempt to link nurses' pay to quality of care.

To open up the health service, Francis wants to refound the NHS on principles of transparency, candour and openness and put the patient's voice at the heart of the service. Again, the coalition may seek to put this report to the service of a more ideological project – reforming the NHS on the lines of choice and competition. But this is a necessary risk. Francis's call for criminal sanctions for those that cause harm and for doctors and managers to have a duty to reveal instances of poor care are necessary steps to make profound change in the NHS.

Politicians must be prepared to address the essential problem – that the health service is an unwieldy, state-run monopoly that has clung unshakeably to its founding principle of free treatment at the point of use, funded by direct taxation. In 1948, it was assumed that demand for care would diminish as the nation’s health improved. In fact, more people now live to an age where they contract diseases that are expensive to treat and expect procedures that are costly to provide. It is doubtful that the radical changes now required can be implemented within the current system. We need less sentimentality of the sort on show last summer and a more realistic debate about the future of the NHS.

money is not the solution – and the Mail has grave doubts whether the proposed Chief Inspector of Hospitals will achieve much more than supplying another layer of bureaucracy, a new set of boxes to tick.What is desperately needed is a change of ethos on the wards where, too often, paper qualifications are thought more valuable than compassion and a willingness to perform simple acts of kindness to the vulnerable.

Taken together, Mr Francis’s calls for a statutory “duty of candour” requiring NHS staff to be open about mistakes, for an established code of conduct the breach of which results in managers’ disqualification, and for a louder voice for nurses are long overdue. As is the creation of a beefed-up regulator, with Ofsted-style inspections focused explicitly on care standards, overseen by a Chief Inspector of Hospitals.

Most important of all, however, is the proposition that care and compassion become the priorities in the recruitment, training and ongoing assessment of medical staff and their auxiliaries. For all that the flawed system has much to answer for, it is too easy to blame the usual suspects of under-staffing, central targets and box-ticking alone. The unpalatable fact remains that in many cases the neglect described is of so basic a nature – the placing of food out of reach, or the failure to provide a drink of water – that even the broken organisation around them cannot entirely absolve individuals for their want of sympathy. Better management, different organisational priorities and closer monitoring can do much. But the change must also come from the heart.

But blogger Flip Chart Rick summarises commentary on the report on Twitter:

Department of Health officials said a raises 'major concerns about the nation’s knowledge of alcohol'. Photograph: Alamy

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